Early Intervention for Children with Fetal Alcohol Spectrum Disorders

FETAL ALCOHOL SPECTRUM DISORDERS (FASD) Early Intervention for Children with Fetal Alcohol Spectrum Disorders Blair Paley, PhD David Geffen School of Medicine at UCLA, USA February 2011 Introduction First identified in the United States over 35 years ago, 1,2 Fetal alcohol syndrome (FAS) is a major birth defect resulting from prenatal alcohol exposure (PAE) and is characterized by a distinct pattern of facial abnormalities, growth retardation and central nervous system dysfunction. The term fetal alcohol spectrum disorders (FASD) 3 is used to reflect the full range of effects associated with PAE, and in addition to FAS, includes partial FAS, alcohol related neurodevelopmental disorder (ARND), and alcohol related birth defects (ARBD). 4 FASD places a significant burden on both affected families and society. The lifetime cost for a person with FAS is estimated to be approximately $2 million, most of which reflects special education and medical and mental health treatment. 5 Subject This paper reviews recent progress in developing early interventions for children with FASD, current challenges in providing services for this high-risk population, and possible directions for future research. Problems The deleterious effects of PAE are evident from infancy among both animals 6,7 and humans, 8-10 with many studies highlighting impairments in self-regulation. In infants and toddlers, PAE is associated with poorer orientation 9,11 and habituation, 12 problems with state 12 and autonomic 11 regulation, sleep abnormalities, 13 and increased level of activity. 14 Studies have also documented greater reactivity to stress, 15,16 alterations in the pain regulatory systems, 17 and increased negative affect and higher rates of insecure attachment behaviour 18-20 in these children. Such problems do not appear to be transient. Significant behavioural, cognitive and emotional difficulties have 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 1

been reported among individuals with FASD throughout life, including intellectual and learning disabilities, executive dysfunction, memory problems, speech and language delays, and internalizing and externalizing behaviour problems. 21-26 Moreover, such individuals are at increased risk for many secondary disabilities, including comorbid psychiatric conditions, school failure, alcohol and substance abuse problems, and delinquency. 27-33 Despite these findings, many children may not be referred for screening until relatively late (if ever), thus missing out on the potential benefit of early intervention. 34 FASD appears to be under-recognized and under-treated, particularly in certain high-risk settings, including psychiatric populations, the child welfare system, and juvenile detention and correctional facilities. 29,35,36 The importance of early identification is highlighted by findings that an early diagnosis is one of the strongest predictors of more positive outcomes for these individuals. 33 Research Context In the last few years, some initial progress has been made in the development of treatments for individuals with FASD, but those focusing on young children have been extremely limited. Early intervention studies present significant methodological challenges with this population. Recruitment of study participants can be challenging when children with FASD are often not identified until school-age. 34 Additionally, as many children with FASD are involved in the child welfare system, obtaining proper consent to enroll them in early intervention programs can be difficult. Selecting an appropriate control group can also be challenging. Given the dearth of services for this population, utilizing no-treatment control groups raises ethical issues, whereas utilizing standard of care control groups may work against finding any significant effects for programs in their early stages of development. Key Research Questions Several key lines of inquiry are currently being addressed in research on early intervention for FASD. Such questions include: 1. How can animal models inform our development of interventions for young children with PAE? 2. To what extent can early intervention programs ameliorate some of the primary deficits seen in infants and young children affected by PAE? 3. What functional domains are appropriate targets of intervention? Recent Research Results 1. Animal studies Several lines of animal research suggest the promise of various prenatal and neonatal interventions. For example, recent studies suggest that lithium may offer some protection against ethanol-induced neuroapoptosis. 37 The benefits of prenatal and postnatal treatment with neuroprotective peptides in mitigating the effects of PAE on brain development have also been reported. 38-40 Studies have also documented the protective effects of various nutrients, including folate, selenium, vitamin C, zinc and choline. 41-45 Other research has demonstrated some positive effects of neonatal handling, postnatal environment enrichment and rehabilitative training on rats and mice with perinatal alcohol exposure. 46 For example, voluntary exercise has been found to improve spatial 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 2

memory among alcohol-exposed rats, 47 whereas introducing complex motor training during the postnatal period effectively remediated the motor deficits of alcohol-exposed rats. 48 2. Programs for mothers with substance abuse problems Treatment programs for mothers with substance abuse problems have been one route to early intervention for young children with FASD, either by providing direct services for children or by connecting mothers to services in their community. The program New Choices provides services for mothers with substance abuse problems and their children aged 0 to 5 years, including addiction counseling, parent education and counseling, peer support and enrichment programs for children. 49 A preliminary evaluation found that mothers demonstrated improvements in depressive symptoms and empathy for their children, and children exhibited improvements in social development. 50 In Seattle s Birth to Three Program, 51 paraprofessionals work with mothers with alcohol and substance use problems to connect them with appropriate services and to facilitate their ability to provide a safe caregiving environment for their children, but do not provide direct intervention services for the children. While positive effects have been found for mothers, at a three-year follow-up, no significant differences were found between the treatment and control group children on a measure of developmental functioning. 52 Such findings suggest there may be limited effects of this type of intervention on child outcomes, particularly if direct early intervention is not provided to the child. 3. Parent-focused intervention While not focusing exclusively on very young children with FASD, some studies have nonetheless included younger children in their samples. 53 One promising approach, Families Moving Forward (FMF), 54 provides supportive behavioural consultation to promote parental self-efficacy and reduce child behaviour problems in families raising children aged 4 to 11 years with FASD. Caregivers who participated in the FMF group reported greater improvements in parenting efficacy and greater reductions in child behaviour problems, compared to caregivers in the community standard of care group. 53 4. Cognitive and educational interventions A small number of cognitive and educational interventions for FASD have also included young children in their samples. Children aged 3 to 10 years with FASD who participated in a socio-cognitive habilitation program in mathematics in addition to receiving educational support showed greater gains on mathematics outcome measures compared to those who received educational support only, 55 and these gains were maintained six months later. 56 To address impairments in working memory, Loomes and colleagues developed an intervention to promote the use of rehearsal strategies among children aged 4 to 11 years with FASD. 57 Children in the experimental condition demonstrated significant improvement in their scores on a digit span task across three sessions whereas the control group showed no such improvement. 5. Adaptive skills training Individuals with FASD show deficits across multiple domains of adaptive functioning, including communication, socialization, and personal and community skills. 58 To address the lack of safety awareness often seen in children with FASD, a computer-based intervention was designed to increase fire and street safety skills in 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 3

children aged 4 to 10 years old with FASD. Children receiving the intervention demonstrated significantly greater gains in safety-related knowledge and appropriate behavioural responses in comparison to the control group. 59 Targeting impairments in social functioning, an evidence-based, manualized, parent-assisted social skills intervention, Children s Friendship Training (CFT), 60 was adapted for use with 6- to 12-year-old children with FASD. Compared to children in the control group, those who received CFT showed significantly greater improvement in their knowledge of appropriate social behaviour and were rated by their parents as having better social skills and fewer behaviour problems following treatment, and these gains were maintained at a three month follow-up. 61 6. Pharmacological interventions Young children are increasingly likely to receive pharmacological interventions to address behaviour problems, 62 and given their increased risk for behaviour problems, children with FASD are likely to receive such interventions. Community and clinic-based surveys indicate that stimulants are commonly used in children with FASD. 63 Despite their common use, research on the efficacy of these medications for FASD has been limited by small samples or has entailed retrospective chart reviews rather than large-scale, double-blind, randomized controlled trials. Studies including children with FASD as young as 3 years old reveal a mixed pattern of findings, with some suggestion that symptoms of inattention may be less responsive to stimulants than hyperactive symptoms. 64,65 Additionally, children with FASD may be especially vulnerable to negative side effects, 66 or may experience atypical reactions to medications. 63 Until more systematic studies have been done examining both the benefits and potential adverse effects of pharmacological regimens with this population, it is important to use caution in prescribing medications for children with FASD, particularly young children whose still-developing brains have already been impacted by PAE. Research Gaps Several lines of inquiry are ripe for further investigation. What are the most effective strategies for identifying young children impacted by PAE so that they may be directed towards appropriate interventions as early as possible? There also remains a need for long-term follow-up studies to examine whether early intervention programs are robust enough to reduce the emergence of secondary disabilities later in life. Future studies might also investigate whether children with FASD can benefit from adaptations of existing early intervention programs, 67 including those that aim to promote more positive parent-child relationships, such as Right From the Start 68 or Attachment Biobehavioral Catch-Up, 69 as well as those designed to better equip parents to care for high risk children in foster care, such as Multidimensional Treatment Foster Care Program for Preschoolers. 70 Identifying moderators of treatment outcomes may allow programs to be tailored for certain subgroups. For example, early interventions may need to be adapted in different ways depending on the family context (i.e., birth families vs. adoptive/foster families). Conclusions Previous research has demonstrated that PAE can significantly compromise an infant s early development, particularly their capacity for self-regulation, which in turn may place them well on course for negative developmental trajectories. Deficits in self-regulation may confer further vulnerability by compromising early parent-child relationships (and potentially jeopardizing stable placements), impairing a child s ability to manage 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 4

stressful situations, and interfering with their mastery of developmentally-appropriate tasks. Encouragingly, a small but growing number of studies have demonstrated with both animals and humans that early intervention can at least partially remediate some of the primary deficits associated with PAE. Such approaches are promising as they may also have the potential to mitigate some of the serious adverse outcomes often seen in individuals with FASD later in life. However, there remains much work to be done in order to identify affected children as early as possible and to develop a comprehensive continuum of services for these children and their families. Implications for Parents, Services and Policy 1. Continued efforts must be made to improve training of professionals who work with young children, such as pediatricians, pediatric nurses, child welfare workers, daycare providers, preschool teachers and early childhood mental health consultants. Such training should include a better understanding of the full range of effects that may be associated with PAE, the importance of asking about and documenting a history of prenatal exposure to not only illicit substances but to alcohol as well, and the importance of early intervention for this population. 2. Better collaboration across different systems of care (e.g., hospitals, child welfare, regional centers, Early Start and Head Start programs) is critical to track and coordinate services for children with FASD. Improved collaboration can help ensure that these children do not slip through the cracks and are directed towards effective interventions. 3. It is critical that intervention for children with FASD involves the entire family system in order to enhance the daily functioning and quality of life for these children and to better prepare and support their parents and caregivers. However, many mental health agencies are precluded from providing integrated services for children and parents by funding requirements. 71 Amending such policies would likely facilitate better parent-child relationships, and promote more stable and nurturing caregiving environments for these vulnerable children. References 1. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet 1973;302(7836):999-1001. 2. Jones KL, Smith DW, Ulleland CN, Streissguth AP. Pattern of malformations in offspring of alcoholic mothers. Lancet 1973;301(7815):1267-1271. 3. Warren K, Floyd L, Calhoun F, Stone D, Bertrand J, Streissguth A, eds. Consensus statement on FASD. Washington, DC: National Organization on Fetal Alcohol Syndrome; 2004. 4. Stratton KR, HOWE CJ, Battaglia, FC, Committee to study Fetal Alcohol Syndrome, Institute of Medicine, eds. Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press; 1996. 5. Lupton C, Burd L, Harwood R. Cost of fetal alcohol spectrum disorders. American Journal of Medical Genetics 2004;127C(1):42-50. 6. Lee S, Choi I, Kang S, Rivier C. Role of various neurotransmitters in mediating the long-term endocrine consequences of prenatal alcohol exposure. Annals of the New York Academy of Sciences 2008;1144:176-188. 7. Zhang X, Sliwowska JH, Weinberg J. Prenatal alcohol exposure and fetal programming: effects on neuroendocrine and immune function. Experimental Biology and Medicine 2005;230(6):376-388. 8. Carter RC, Jacobson SW, Molteno CD, Chiodo LM, Viljoen D, Jacobson JL. Effects of prenatal alcohol exposure on infant visual acuity. Journal of Pediatrics 2005;147:473-479. 9. Kable JA, Coles CD. The impact of prenatal alcohol exposure on neurophysiological encoding of environmental events at six months. Alcoholism: Clinical and Experimental Research 2004;28:489-496. 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 5

10. Zeskind PS, Coles CD, Platzman KA, Schuetze P. Cry analysis detects subclinical effects of prenatal alcohol exposure in newborn infants. Infant Behavior and Development 1996;19:497-500. 11. Smith I, Coles C, Lancaster J, Fernhoff P, Falek A. The effect of volume and duration of exposure on neonatal physical and behavioral development. Neurobehavioral Toxicology and Teratology 1986;8:375-381. 12. Streissguth AP, Barr HM, Martin DC. Maternal alcohol use and neonatal habituation assessed with the Brazelton scale. Child Development 1983;54:1109-1118. 13. Chen ML, Carmichael Olson H. Caregiver report of sleep problems in children with fetal alcohol spectrum disorders. American Journal of Respiratory and Critical Care Medicine 2008;177:A707. 14. Coles CD, Smith I, Fernhoff PM, Falek A. Neonatal neurobehavioral characteristics as correlates of maternal alcohol use during gestation. Alcoholism: Clinical and Experimental Research 1985;9:454-460. 15. Haley DW, Handmaker NS, Lowe J. Infant stress reactivity and prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research 2006;30:2055-2064. 16. Jacobson SW, Bihun JT, Chiodo LM. Effects of prenatal alcohol and cocaine exposure on infant cortisol levels. Developmental Psychopathology 1999;11:195-208. 17. Oberlander TF, Jacobson SW, Weinberg J, Grunau RE, Molteno CD, Jacobson JL. Prenatal alcohol exposure alters biobehavioral reactivity to pain in newborns. Alcoholism: Clinical and Experimental Research 2010;(34)4:681-692. 18. Lemola S, Stadlmayr W, Crob A. Infant irritability: The impact of fetal alcohol exposure, maternal depressive symptoms, and low emotional support from the husband. Infant Mental Health Journal 2009;30:57-81. 19. O Connor MJ. Prenatal alcohol exposure and infant negative affect as precursors of depressive features in children. Infant Mental Health Journal 2001;22:291-299. 20. O Connor MJ, Sigman M, Kasari C. Interactional model for the association among maternal alcohol consumption, mother-infant characteristics and infant cognitive development. Infant Behavior and Development 1993;16:177-192. 21. Burd L, Klug, MG, Martsolf, JT, Kerbeshian J. Fetal alcohol syndrome: neuropsychiatric phenomics. Neurotoxicology and Teratology 2003;25:697-705. 22. Guerri C, Bazinet A, Riley EP. Foetal alcohol spectrum disorders and alterations in brain and behavior. Alcohol and Alcohol Research 2009;44:108-114. 23. Kodituwakku PW. Defining the behavioral phenotype in children with fetal alcohol spectrum disorders: A review. Neuroscience and Biobehavioral Reviews 2007;31:192-201. 24. Kvigne VL, Leonardson GR, Neff-Smith M, Brock E, Borzelleca J, Welty TK. Characteristics of children who have full or incomplete Fetal Alcohol Syndrome. Journal of Pediatrics 2004;145:635-640. 25. Rasmussen C. Executive functioning and working memory in Fetal Alcohol Spectrum Disorder. Alcoholism: Clinical and Experimental Research 2005;29:1359-1367. 26. Streissguth AP. Offspring effects of prenatal alcohol exposure from birth to 25 years: The Seattle Prospective Longitudinal study. Journal of Clinical Psychology in Medical Settings 2007;14:81-101. 27. Alati R, Clavarino A, Najman JM, O Callaghan M, Bor W, Mamun AA, Williams GM. The developmental origin of adolescent alcohol use: Findings from the Mater University Study of Pregnancy and its outcomes. Drug and Alcohol Dependence 2008;93:136-143. 28. Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Archives of General Psychiatry 2003;60:377-385. 29. Burd L, Selfridge R, Klug M, Bakko S. Fetal alcohol syndrome in the United States corrections system. Addiction Biology 2004;9:177-178. 30. Fast DK, Conry J. Fetal Alcohol Spectrum Disorders and the criminal justice system. Developmental Disabilities Research Reviews 2009;(15)3:250-257. 31. Huggins J, Grant T, O Malley K, Streissguth AP. Suicide attempts among adults with Fetal Alcohol Spectrum Disorders: Clinical implications. Mental Health Aspects of Developmental Disabilities 2008;11:33-41. 32. O Connor MJ, Paley, B. Psychiatric conditions associated with prenatal alcohol exposure. Developmental Disabilities Research Review 2009;15(3):225-34. 33. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O Malley K, Young JK. Risk factors for adverse life outcomes in Fetal Alcohol Syndrome and Fetal Alcohol Effects. Developmental and Behavioral Pediatrics 2004;25:228-238. 34. Olson HC, Jirikowic T, Kartin D, Astley S. Responding to the challenge of early intervention for Fetal Alcohol Spectrum Disorders. Infants and Young Children 2007;20:172-189. 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 6

35. Astley SJ, Stachowiak J, Clarren SK, Clausen, C. Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population. Journal of Pediatrics 2002;141:712-717. 36. O Connor MJ, Mccracken J, Best A. Under recognition of prenatal alcohol exposure in a child inpatient psychiatric setting. Mental Health Aspects of Developmental Disabilities 2006;9:105-108. 37. Luo J. Lithium-mediated protection against ethanol neurotoxicity. Frontiers in Neuroscience 2010;4;41. 38. Incerti M, Vink J, Roberson R, Wood L, Abebe D, Spong CY. Reversal of alcohol-induced learning deficits in the young adult in a model of fetal alcohol syndrome. Obstetrics & Gynecology 2010;115:350-6. 39. Incerti M, Vink, J, Roberson R, Benassou I, Abebe D, Spong CY. Prevention of the alcohol-induced changes in brain-derived neurotrophic factor expression using neuroprotective peptides in a model of fetal alcohol syndrome. American Journal of Obstetrics and Gynecology 2010;202(5);457e1-457. 40. Zhou FC, Fang C, Goodlett C. Peptidergic agonists of activity-dependent neurotrophic factor protect against prenatal alcohol-induced neural tube defects and serotonin neuron loss. Alcoholism: Clinical and Experimental Research 2008;32:1361-1371. 41. Naseer MI, Lee HY, Kim MO. Neuroprotective effect of Vitamin C against the ethanol and nicotine modulation of GABA(B) receptor and PKAalpha expression in prenatal rat brain. Synapse 2010;64(6):467-477. 42. Ojeda ML, Nogales F, Jotty K, Barrero Mj, Murillo ML, Carreras O. Dietary selenium plus folic acid as an antioxidant therapy for ethanolexposed pups. Birth Defects Research 2009;86(6):490-495. 43. Serrano M, Han MD, Brinez P, & Linask KK. Fetal alcohol syndrome: Cardiac birth defects in mice and prevention with folate. American Journal of Obstetrics and Gynecology 2010;203(1);75e7-75. 44. Summers BL, Rofe AM, Coyle P. Dietary zinc supplementation throughout pregnancy protects against fetal dysmorphology and improves postnatal survival after prenatal ethanol exposure in mice. Alcoholism: Clinical and Experimental Research 2009;33(4):591-600. 45. Thomas JD, Abou EJ, Dominguez HD. Prenatal choline supplementation mitigates the adverse effects of prenatal alcohol exposure on development in rats. Neurotoxicology and Teratology 2009;31(5):303-311. 46. Hannigan JH, O Leary-Moore SK, Berman RF. Postnatal environmental or experiential amelioration of neurobehavioral effects of perinatal alcohol exposure in rats. Neuroscience and Biobehavioral Review 2007;31:202-211. 47. Thomas JD, Sather TM, Whinery LA. Voluntary exercise influences behavioral development in rats exposed to alcohol during the neonatal brain growth spurt. Behavioral Neuroscience 2008;122:1264-1273. 48. Guerri C, Pascual M, Garcia-Minguillán, Charness ME, Wilkemeyer MF, Klinstova AY, Goodlett CR, Greenough WT, Sakata-Haga H, Dominguez HD, Thomas JD. Fetal alcohol effects: Potential treatments from basic science. Alcoholism: Clinical and Experimental Research 2005;29:1074-1079. 49. Sword W, Niccols A, Fan AM. New Choices for women with addictions: perceptions of program participants. BMC Public Health 2004;4:10. 50. Niccols A, Sword W. New Choices for substance using mothers and their young children: Preliminary evaluation. Journal of Substance Use 2005;10:239-251. 51. Grant TM, Ernst CC, Streissguth AP. Intervention with high-risk alcohol and drug-abusing mothers: Administrative strategies of the Seattle model of paraprofessional advocacy. Journal of Community Psychology 1999;27(1):1-18. 52. Kartin D, Grant TM, Streissguth, AP, Sampson PD, Ernst CC. Three-year developmental outcomes in children with prenatal alcohol and drug exposure. Pediatric Physical Therapy 2002;14(3):145-153. 53. Bertrand J, Interventions for Children with Fetal Alcohol Spectrum Disorders Research Consortium. Interventions for children with fetal alcohol spectrum disorders: Overview of findings for five innovative research projects. Research in Developmental Disabilities 2009;30:986-1006. 54. Olson HC, Brooks A, Quamma J, Lehman K, Ranna M, Davis C, Kerns K, Astley S. Efficacy of a new model of behavioral consultation for families raising school-aged children with FASDs and behavior problems. In preparation. 55. Kable JA, Coles, CD, Taddeo E. Socio-cognitive habilitation using the math interactive learning experience program for alcohol affected children. Alcoholism: Clinical and Experimental Research 2007;31:1425-1434. 56. Coles CD, Kable JA, Taddeo E. Math performance and behavior problems in children affected by prenatal alcohol exposure: Intervention and follow-up. Journal of Developmental & Behavioral Pediatrics 2009;30:7-15. 57. Loomes C, Rasmussen C, Pei J, Manji S, Andrew G. The effects of rehearsal training on working memory span of children with fetal alcohol spectrum disorder. Research in Developmental Disabilities 2008;29:113-124. 58. Jirikowic T, Kartin D, Olson HC. Children with Fetal Alcohol Spectrum Disorders: A descriptive profile of adaptive function. Canadian Journal of Occupational Therapy 2008;75:238-248. 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 7

59. Coles CD, Strickland DC, Padgett L, Bellmoff L. Games that work : Using computer games to teach alcohol-affected children about fire and street safety. Research in Developmental Disabilities 2007;28:518-530. 60. Frankel F, Myatt R. Children s friendship training. New York, NY: Brunner-Routledge Publishers; 2003. 61. O Connor MJ, Frankel F, Paley B, Schonfeld AM, Carpenter E, Laugeson E, Marquardt R. A controlled social skills training for children with fetal alcohol spectrum disorders. Journal of Consulting and Clinical Psychology 2006;74:639-648. 62. Fanton J, Gleason MM. Psychopharmacology and preschoolers: a critical review of current conditions. Child and Adolescent Psychiatric Clinics of North America 2009;18(3):753-71. 63. O Malley KD, Nanson J. Clinical implications of a link between Fetal Alcohol Spectrum Disorder and Attention-Deficit Hyperactivity Disorder. Canadian Journal of Psychiatry 2002;47:349-354. 64. Doig J, McLennan JD, Gibbard WB. Medication effects on symptoms of attention-deficit hyperactivity disorder in child with fetal alcohol spectrum disorder. Journal of Child and Adolescent Psychopharmacology 2008;18:365-371. 65. Oesterheld JR, Kofoed L, Tervo R, Fogas B, Wilson A, Fiechtner H. Effectiveness of methylphenidate in Native American children with fetal alcohol syndrome and/or attention deficit/hyperactivity disorder: A controlled pilot study. Journal of Child and Adolescent Psychopharmacology 1998;8:39-48. 66. Coe J, Sidders J, Riley K, Waltermire J, Hagerman R. A survey of medication responses in children and adolescents with fetal alcohol syndrome. Mental Health Aspects of Developmental Disabilities 2001;4:148-155. 67. Olson HC, Montague R. An innovative look at early intervention for children affected by prenatal alcohol exposure. In: Adubato S, Cohen D, eds. Prenatal alcohol use and Fetal Alcohol Spectrum Disorders: Diagnosis, assessment and new directions in research and multimodal treatment. In press. 68. Niccols A. Right From the Start : Randomized trial comparing an attachment group intervention to supportive home visiting. The Journal of Child Psychology and Psychiatry 2008;49:754-764. 69. Dozier, M, Lindhiem, O, Lewis, E, Bick, J, Bernard, K, Peloso, E. Effects of a foster parent training program on children s attachment behaviors: Preliminary evidence from a randomized clinical trial. Child and Adolescent Social Work Journal 2009;26:321-332. 70. Fisher PA, Kim HK. Intervention effects on foster preschoolers attachment-related behaviors from a randomized trial. Prevention Science 2007;8:161-170. 71. Children s Law Center of Los Angeles. Making reform real: Addressing the mental health needs of children in the dependency system. Monterey Park, CA: Children's Law Center of Los Angeles; 2007. 2011-2017 CEECD / SKC-ECD FETAL ALCOHOL SPECTRUM DISORDERS (FASD) 8